Editorial

576 www.thelancet.com Vol 383 February 15, 2014

For the Nuffi eld Trust report see http://www.nuffi eldtrust.org.uk/

sites/fi les/nuffi eld/publication/140206_the_

francis_inquiry.pdf

In February, 2013, the second and fi nal report of the Mid Staff ordshire NHS Foundation Trust Public Inquiry, chaired by Robert Francis QC, was damning in its conclusion: “failings at every level” of the NHS had allowed appalling cases of care to continue at the hospital for nearly a decade. The Francis report made 290 recommendations for change to put the patient at the heart of everything the NHS does. A year on, what progress has been made? In a new report, the Nuffi eld Trust assesses changes at the hospital level based on a survey of a third of England’s acute care trusts and in-depth interviews with senior members of staff .

The report found many trusts engaging in internal and external initiatives to understand and improve the quality of care in response to the Francis inquiry and several other linked reports that followed (eg, Bruce Keogh’s mortality review). Trusts reported using diff erent data sources and sources of intelligence to track the quality and safety of care, including internal peer review of specifi c wards and specialties, meetings with complainants and their families, and use of a wide

range of metrics to monitor basic aspects of care such as falls, pressure ulcers, and staffi ng levels.

However, the trusts noted that the tensions between fi nancial performance and quality of care that were, in part, responsible for the Mid Staff ordshire care scandal still existed, and had even intensifi ed since funding for the NHS has been frozen in real terms since 2011–12. Trust leaders felt that the multiple sources of external scrutiny they faced along with fi nancial and performance targets (eg, waiting times) were leading to pressure on their teams, which could undermine work to improve and manage services.

The lessons learned from Mid Staff ordshire have resulted in clear actions in acute trusts. Whether these activities lead to better patient care needs to be monitored closely, as does the existence of genuine cultural change among staff and the wider NHS system. The need to continue to strive for improvement comes at a time of massive service reorganisation and increasing fi nancial diffi culty. The challenges are immense but the overriding aim—to value the patient fi rst and foremost—must never be forgotten. The Lancet

The Francis report: a year on

Protecting children in confl ictThe UN Convention on the Rights of the Child states that children have rights to protection, health, education, and fair treatment. For the children killed, tortured, raped, and abused in confl icts, these rights are far beyond reach.

Last week, a report of the UN Secretary-General on the situation of children and armed confl ict in Syria detailed grave violations against children, committed by all parties. More than 10 000 children are estimated to have been killed since March, 2011, many more injured, and countless psychologically aff ected. The document contains reports of the imprisonment, torture, and murder of children, and their exposure to unthinkable cruelties. Sexual violence is used to harm, humiliate, and intimidate young victims and those forced to witness. Children have been recruited into warfare, abducted for ransom, and used as human shields. They have lost families, homes, schools, and health care.

Tragically, similar reports have surfaced from other nations gripped by confl ict. Brutality against children in the Central African Republic is said to be at unprecedented levels; children are being beheaded and maimed amid

widespread sexual violence, and an estimated 6000 are associated with armed groups. For children who escape confl ict, the psychological scars from witnessing horrifi c events endure. In South Sudan, orphaned and displaced children will struggle to fi nd their emotional needs met in a country battered by decades of civil war, many living in camps where their security and health are threatened. Children born as refugees might not have birth certifi cates, crucial to ensure they can access their rights.

By committing atrocities to children, fi ghters destroy their nation’s future. Damage to children’s health, education, and psychological wellbeing will delay a country’s recovery; without decisive action, a generation in every war zone could become the lasting casualties. Better protection of children is paramount. The Syrian Government has legislated greater child protection, but violations threaten to continue while war lasts. During the confl icts and the aftermath, international communities must seek to heal emotional wounds and safeguard children’s rights. The Lancet

For the full UN report see http://www.un.org/ga/search/view_

doc.asp?symbol=S/2014/31

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